Sustainability, Midwifery and Birth pot

Divided into three parts, the book discusses: • The politics of midwifery and sustainability • Midwifery as a sustainable health care practice • Supporting an ecological approach to pare

Sustainability, Midwifery and Birth

Environmental awareness and sustainability are vitally important concepts

in the twenty-first century and, as a low environmental impact health careprofession, midwifery has the potential to stand as a model of excellence.This innovative volume promotes a sustainable approach to midwifery prac -tice, philosophy, business administration and resource management Drawing

on an interdisciplinary body of knowledge, this international collection ofexperts explore the challenges, inviting readers to critically reflect on the issuesand consider how they could move to effect changes within their own workingenvironments Divided into three parts, the book discusses:

• The politics of midwifery and sustainability

• Midwifery as a sustainable health care practice

• Supporting an ecological approach to parenting

Sustainability, Midwifery and Birth identifies existing models of sustainable

midwifery practice, such as the continuity of care model, and highlights thepotential for midwifery as a role model for ecologically sound health care pro -vision This unique book is a vital read for all midwives and midwifery students

interested in sustainable practice Contributors include: Sally Baddock, Carol Bartle, Ruth Deery, Nadine Pilley Edwards, Ina May Gaskin, Megan Gibbons, Carolyn Hastie, Barbara Katz-Rothman, Mavis Kirkham, Nicky Leap, Ruth Martis, Zoë Meleo-Erwin, Jenny L Meyer, Jo Murphy-Lawless, Mary Nolan, Sally Pairman and Sally Tracy.

Lorna Davies is a Midwife Lecturer at Christchurch Polytechnic Institute of

Technology, New Zealand She was formerly a Lecturer in Midwifery at AngliaRuskin University and is Co-Director of www.withwoman.co.uk She stillcarries a small midwifery caseload as a self-employed midwife

Rea Daellenbach is a Midwife Lecturer at Christchurch Polytechnic Institute

of Technology, New Zealand She has a ministerial appointment on theMidwifery Council of New Zealand

Mary Kensington is Co-Head of Midwifery at Christchurch Polytechnic

Institute of Technology, New Zealand

Sustainability, Midwifery and Birth

Edited by Lorna Davies,

Rea Daellenbach and Mary

Kensington

by Routledge

2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN

Simultaneously published in the USA and Canada

by Routledge

270 Madison Avenue, New York, NY 10016

Routledge is an imprint of the Taylor & Francis Group, an informa business

© 2011 Lorna Davies, Rea Daellenbach and Mary Kensington.

Individual chapters; the contributors.

All rights reserved No part of this book may be reprinted or

reproduced or utilized in any form or by any electronic,

mechanical, or other means, now known or hereafter

invented, including photocopying and recording, or in any

information storage or retrieval system, without permission in

writing from the publishers.

British Library Cataloguing in Publication Data

A catalogue record for this book is available

from the British Library

Library of Congress Cataloging-in-Publication Data

Sustainability, midwifery, and birth/edited by Lorna Davies,

Rea Daellenbach, and Mary Kensington.

p.; cm.

Includes bibliographical references.

1 Midwifery 2 Sustainability I Davies, Lorna

II Daellenbach, Rea III Kensington, Mary.

[DNLM: 1 Midwifery 2 Conservation of Natural Resources.

3 Infant Care 4 Parturition 5 Politics 6 Social

This edition published in the Taylor & Francis e-Library, 2010.

To purchase your own copy of this or any of Taylor & Francis or Routledge’s

collection of thousands of eBooks please go to www.eBookstore.tandf.co.uk.

ISBN 0-203-84124-7 Master e-book ISBN

1 Globalization, midwifery and maternity services:

struggles in meaning and practice in states under

5 ‘Relationships – the glue that holds it all together’:

N I C K Y L E A P , H A N N A H D A H L E N , P A T B R O D I E ,

6 Promoting a sustainable midwifery workforce:

R U T H D E E R Y

7 Sustained by joy: the potential of flow experience

M A V I S K I R K H A M

8 The birthing environment: a sustainable

C A R O L Y N H A S T I E

9 Sustainable midwifery education: a case study

S A L L Y P A I R M A N

10 Mentoring new graduates: towards supporting

M A R Y K E N S I N G T O N

11 Good housekeeping in midwifery practice:

13 Breastfeeding and sustainability: loss, cost,

‘choice’, damage, disaster, adaptation and

16 Co-sleeping: an ecological parenting practice 207

S A L L Y B A D D O C K

17 How can birth activism contribute to sustaining

change for better birthing for women, families

R E A D A E L L E N B A C H A N D N A D I N E P I L L E Y E D W A R D S

Planet and placenta: a cycle of seasonal

correspondence between two old friends

J E N N Y L M E Y E R

Notes on contributors

Sally Baddock B.Sc Dip Tchng, Ph.D has been involved in the SIDS

(Sudden Infant Death Syndrome) research area for over 10 years She has aB.Sc majoring in physiology and completed her Ph.D in 2005 Sheinvestigated the physiology and behaviour of infants while bedsharingcompared to cot-sleeping Findings from this study have been published inhigh-ranking international peer-reviewed journals and presented at manyinternational and national conferences Sally has also taught physiol ogy atundergraduate and postgraduate level to students of midwifery and otherhealth professions for over 20 years She is currently Associate Head of School

of Midwifery at Otago Polytechnic

Carol Bartle RN, RM, IBCLC, PGDip Child Advocacy, MHeal.Sc heard

E F Schumacher speak in England in the early 1970s, thanks to herinspiring cousin Cynthia Stein Further exposure, to environmental issues,was also directly as a result of work by Stein who lobbied for thedevelopment of recycling systems in West Yorkshire Later in the mid-1970s, after Carol moved to Christchurch, New Zealand, she worked as avolunteer at the Environment Centre, learning from another inspirationalperson, the late Rod Donald, who became the co-leader of the NZ GreenParty Carol has developed an enduring interest in optimal and safe infantfeeding and women’s health Over the years she has worked as a midwifeand breastfeeding advocate and is concerned about the unethical marketing

of substitutes for breastmilk and the growing market push for dairydevelopment to the detriment of the environment and health

Pat Brodie is the Immediate Past President of the Australian College

of Midwives and Adjunct Professor of Midwifery at the University ofTechnology, Sydney For more than two decades, she has contributed topolicy change and practice development that has enhanced continuity ofcare and the recognition of midwives as primary carers Pat has had aleadership role in major reforms to midwifery education, regulation andpractice throughout Australia

Rea Daellenbach (editor), BA (Hons), Ph.D (Sociology), was introduced to

the ecology movement by her father as a small child She became active

in the Home Birth Association in the mid-1980s and, as a consumerrepresentative, was involved in the establishment of the New ZealandCollege of Midwives At the same time she completed a Ph.D in sociologyabout the home birth movement in New Zealand In 2004 she wasappointed as a ‘lay person’ to the inaugural Midwifery Council of NewZealand Currently, she is a Lecturer for the School of Midwifery at theChristchurch Polytechnic Institute of Technology, New Zealand.

Hannah Dahlen is an Associate Professor of Midwifery at the University

of Western Sydney and is the Vice President of the Australian College

of Midwives She is well known for her commitment to the reforming ofmaternity care in Australia, her skills in political negotiation and her creativeexpertise in media liaison Hannah has published widely about research that

is focussed on improving midwifery practice and woman-centred care

Lorna Davies (editor), RM, B.Sc (Hons), PGCEA, MA, is a UK qualified

midwife who has worked in midwifery education for the last 15 years Shehas published extensively in midwifery journals and texts and has editedtwo midwifery titles in recent years She has been interested in environ -mental issues for a considerable length of time and was an executivecommittee member of the Women’s Environmental Network (WEN) forseveral years During this time she co-edited a book on green issues andcontributed to several TV documentaries Lorna is currently a principallecturer in midwifery at Christchurch Polytechnic Institute of Technology

in New Zealand She also carries a small caseload as a selfemployed mid wife and is a childbirth educator She is presently undertaking a doctoralthesis exploring midwifery practice within a framework of sustainability

-Ruth Deery RGN, RM, ADM, B.Sc (Hons), Ph.D., is Reader in Midwifery

at the University of Huddersfield Over a career spanning 34 years she hasworked continuously as a midwife and academic She worked for manyyears on a large, busy delivery suite but now works mainly in birth centresand community midwifery As an academic her key interest at doctorallevel was in applying sociological and political theory and action researchmethodology to the organizational culture of midwifery in the NationalHealth Service (NHS) in England Since then her main work has been inthe maternity services and women’s health in the new NHS, with particularinterests in organizational change, public policy, emotions and care andcritical obesity using qualitative, observational and ethnographic methods.Her work has been widely published in refereed journals

Nadine Pilley Edwards, Ph.D., has worked with the Association for Improve

-ments in the Maternity Services (AIMS) since 1980 She has an honoraryresearch post at Sheffield Hallam University and is one of the Directors ofthe Pregnancy and Parents Centre in Edinburgh, Scotland, a charity workingwith pregnant women and families She lectures and writes on maternity issues

in the UK and overseas Her book, Birthing Autonomy, articles and chapters

focus on the relationships between woman and midwives, and the politicalcomplexities of choice, home birth, safety and risk.

Ina May Gaskin, MA, CPM, Ph.D (Hon.), is founder and Director of the

internationally acclaimed Farm Midwifery Center in Tennessee where shehas attended more than 1,200 births She is a prolific writer and has

authored several books including the hugely influential textbook, Spiritual Midwifery, and was editor of Birth Gazette for 22 years She was President

of the Midwives’ Alliance of North America from 1996 to 2002 and hasreceived many awards In 2003 she was chosen as Visiting Fellow of MorseCollege, Yale University and more recently, in 2009, was granted honoraryPh.D status by Thames Valley University in the UK Now in her seventiesshe continues to campaign for improvements in maternity services with acurrent focus on maternal mortality in the US

Megan Gibbons, M.Sc (1st Class Hons), Dip Diet, BCApS, currently teaches

nutrition, bioscience and sustainable development for the Bachelor ofMidwifery at Otago Polytechnic, as well and teaching nutrition at post-graduate level and supervising Master’s degree students She is currentlyenrolled in a Ph.D at Auckland University, where she is examining therole of nutrition as a risk factor for community acquired pneumonia in0–5-year-old children She has published a number of articles in the area

of nutrition and paediatrics and during pregnancy

Carolyn Hastie, RM, RN, Dip Teach., IBCLC; Certificate Sexual and

Reproductive Health; Grad Dip PHC; FACMI; M.Philosophy; Ph.D.candidate As a result of her work with childbearing women over 35 years,Carolyn is fascinated by the role of the environment, emotions andperceptions in human behaviour, experience and relationships In 2005,her expertise in creating the right environment for women to birth wellwas sought to establish a publically funded, community based midwiferyservice Located in a specially designed, calm, relaxing woman-centred birthcentre, the service provides women with the option to birth at home or atthe centre Carolyn is now the Senior Midwifery Lecturer at the University

of Newcastle

Barbara Katz-Rothman, Professor of Sociology at the City University of

New York, serves on the faculties of Women’s Studies, Disability Studiesand Public Health, and is Visiting Professor at the University of Plymouth

in the UK and the Charite Medical School in Berlin Her books include

Weaving a Family: Untangling Race and Adoption; Genetic Maps and Human Imaginations; Recreating Motherhood; The Tentative Pregnancy; In Labor; and with Wendy Simonds, Laboring On.

Mary Kensington (editor), RM, ADM, Dip Tchg Tertiary., BA, MPH, has

practised as a midwife in a variety of maternity settings around the world.For the last 15 years she has worked in midwifery education at Christchurch

Polytechnic Institute of Technology and is currently a Principal Lecturer andCo-Head of Midwifery Mary was responsible for setting up the three-yeardirect-entry midwifery degree in Christchurch, which commenced in 1997.Recently she led the Christchurch arm of the new innovative collaborativeBachelor of Midwifery programme with Otago Polytechnic that provides forflexible and blended delivery Mary also carries a small caseload as a self-employed midwife and provides rural locum cover.

Mavis Kirkham is Emeritus Professor of Midwifery at Sheffield Hallam

University and holds honorary professorial positions at the University ofHuddersfield and the University of Technology, Sydney She has workedcontinuously as a midwife researcher and a clinical midwife for nearly 40years She is now interested in reflecting and writing on midwifery in itswider context Her central professional concern is with normal birth: theconditions that foster it and its enabling effects upon mothers, familiesand midwives She has long been concerned with how birth stories arenegotiated and adjusted and the impact of these stories on tellers andhearers

Nicky Leap is an Adjunct Professor of Midwifery at the University of

Technology, Sydney and a Visiting Senior Research Fellow at Kings CollegeLondon For over 25 years, in both England and Australia, Nicky has beeninvolved in developing midwifery continuity of care in the public healthsector She has written extensively about the importance of community-based midwifery and woman-centred care and has led reforms in Australianmidwifery education standards

Ruth Martis, RM, RGON, ADN, Grad Dip Tchg., BA, MA, IBCLC, has

practiced as a midwife for over 30 years in a variety of settings, includinghome births She has been involved in research, particularly in South East Asia, and midwifery education for a number of years Ruth is currently

a full-time midwifery lecturer at Christchurch Polytechnic Institute ofTechnology (CPIT) Ruth is a fledging Cochrane Systematic Review authorand interested in clinical guideline practice development Her Master’sdegree thesis focused on her other passion – young pregnant women andtheir antenatal education needs While active in her home birth practiceshe was introduced to sustainability through a home birth family Theyencouraged her to critically assess what she was using in her midwiferypractice

Zoë Meleo-Erwin is a Ph.D candidate in sociology and a MA student in

disability studies at the City University of New York Graduate Center.Her research interests include the disciplinary and productive effects ofdiscourse around the obesity epidemic; similarities and differences betweendisability rights, transgender and fat activist movements; and the socialand bodily experiences of weight-loss surgery patients She is the author

of “Reproductive Technology: Welcome to the Brave New World” in

Redesigning Life: The Worldwide Challenge to Genetic Engineering, Brian Tokar,

ed and “Fat Activism” in The Cultural Encyclopedia of the Body, Victoria

Pitts-Taylor, ed

Jenny L Meyer, RN, BA, Dip Journalism, lives on a fault line with spectacular

harbour views in Wellington, New Zealand She and her husband Mark, havethree children, who were all born at home and breastfed in Auckland in the1990s The daughter of a blind father and partially sighted mother who areboth physiotherapists, Jenny was conceived in London and born in NewZealand Jenny has nursed for 20 years in surgical, mental health andmaternity settings, and currently works two nights per week inWellington’s Neonatal Intensive Care Unit In 2008 she trained as ajournalist and now also works part time for Radio New Zealand Inter -national, researching and writing news stories from around the Pacific

Jo Murphy-Lawless, BA, MA, Ph.D., works as a sociologist focusing

primarily on the politics of birth Much of her writing about childbirthexplores the troubling levels of complexity that confront women andmidwives alike She teaches in the School of Nursing and Midwifery,Trinity College Dublin where she has been involved with the development

of the four-year undergraduate direct-entry midwifery programme She isalso a member of the Birth Project Group, which comprises academics,birth activists and midwives in Dublin and Edinburgh who are seeking tobuild a collective approach to better support women and midwives intraining

Mary Nolan trained as a nurse in Cheltenham, England, in the 1980s and

subsequently as a childbirth educator with the National Childbirth Trust,the largest European charity for birth and parenting education She gained

her Ph.D., entitled Empowerment and Antenatal Education, at the University

of Birmingham From the 1990s onwards she became known as a writerand speaker on choice and decision-making in maternity, education fornormal birth and the role of the voluntary sector in health care, withnumerous articles appearing in professional and academic journals She haslectured across the UK, in Europe, and in New Zealand and Australia In

2007, she became Professor of Perinatal Education at the University ofWorcester

Sally Pairman, MNZM, BA, RGON, RM, MA, D.Mid is Head of the School

of Midwifery and the Health and Community Group Manager at OtagoPolytechnic, Dunedin, New Zealand; Inaugural Chair of the MidwiferyCouncil of New Zealand; honorary member, previous President and foundermember of the New Zealand College of Midwives; co-chair of Inter nationalConfederation of Midwives Regulation Standing Committee and Regula -

tion Taskforce; co-author, with Karen Guilliland, of Midwifery Partnership:

A Model for Practice, a monograph describing a theoretical model of mid

-wifery as a partnership between the woman and the midwife; and co-editor

and author of several chapters in the midwifery textbook Midwifery: Preparation for Practice In 2008 Sally was made a Member of the Order of

New Zealand for her services to midwifery and women’s health

Jean Patterson, RM, RN, BA, MA, Ph.D., is a Senior Lecturer and Post

-graduate Programme Co-ordinator at the School of Midwifery, OtagoPolytechnic, in Dunedin Jean came to teaching after many years in a variety

of nursing and midwifery roles in rural New Zealand The sustainability

of a rural birth option for women continues to be both her passion andresearch interest

Juliet Thorpe has been a midwife for 20 years and has been working as a

home birth midwife in Christchurch NZ for 18 years She completed herMaster’s degree in 2005, which investigated strategies for sustainingmidwifery collegial relationships, and continues to be a passionate advocatefor women choosing to birth at home

Sally Tracy is Professor of Midwifery at the University of Sydney and is the

research leader on two large nationally-funded three-year research projectsevaluating midwifery care in the maternity system Professor Tracy is based at the Royal Hospital for Women, Sydney where she is involved inevaluating caseload midwifery care She is a co-editor and author of several

chapters in the midwifery textbook, Midwifery: Preparation for Practice She

is a regular presenter at conferences both nationally and internationallyand is currently the Pacific representative on the ICM Taskforce on GlobalStandards for Midwifery Education

Nei r¯a te mihi kau atu ki k¯a aroaro mauka o te motu, ki a koutou hoki k¯a iwi e noho ana ki t¯en¯a pito, ki t¯en¯a pito tai¯awhio i te ao t¯enei te mihi a Aoraki mauka ki a koutou katoa Nau mai, nau mai, tauti mai r¯a.

Greetings to all of the lofty peaks of the land, and to all peoples from around the world, from Aoraki mountain (and those that reside beneath him) Welcome, welcome, welcome.

To identify oneself as an indigenous M¯aori woman of Aotearoa me TeWaipounamu means to locate myself topographically, by the landmarks that

simultaneously represent who I come from and where I come from My name

is not the defining landmark in the sequence of remembering but that of themountains and rivers that physically and spiritually link me to my tupuna/ancestors My landscape is named after particular ancestors and thereforewhenever I walk the Papa/Whenua/Earth I also reconnect with those whocame before me

The earth is named Papatuanuku and is representative of the archetypal

mother and also pa-pa (explosion), atua (from the ages/other dimensions) and nuku (shift in energy) also related to nukunuku (unconscious), therefore

embedded through esoteric language in the naming of the mother are ideasaround spirituality, motion and a powerful shift in energy or intuition As amidwife I have also seen these states represented in the birthing womanunrestricted and connected to her own mana/prestige/power and awe, whomoves through birth as a powerful state of being to welcome the next genera -tion into this new world For M¯aori there is a welcoming ceremony calledthe powhiri where our elder women call on the visiting peoples with akeening call we know as the kaikaranga – this creates a safe world pathwaybetween this world and the one of each respective groups ancestors so that

we might greet each other and become one for a specific time and purpose

I see the midwives’ role in birth as parallel to this idea – she is the link tocreating that space, the safe world pathway for this birthing journey Theoverriding theme is of connection The link between birth and the whenua/land on both a terrestrial and a celestial level are continuously reinforced in

metaphoric language and stories, in the ways we walk the land and in theway we name ourselves as descendents of this birthing mama and her arche -typal mama Every time whakapapa are recited the links between the differentstates/times/dimensions are remembered and we are reminded of our placewithin this as a part of something larger and more wondrous than any onecomponent One where all dimensions of health must be considered as neces -sary for health to occur including but not limited to the physical, but alsothe spiritual, environmental and mental.

For me as a M¯aori midwife the link between the whenua/land and birthing

is embodied within the symbolism and language handed down through time.For example, the word whenua denotes land and also placenta, and M¯aori returnthe whenua back to the localized place they whakapapa to as another way ofrecreating the link from one nurturing place to another, this allows us to claimturangawaewae, a place to stand for the rest of our time and for our futurechildren

Many M¯aori creation traditions use symbols of childbirth, the growth

of trees, thought, energy and the fertile earth to convey the idea of constant,repeated creation These symbols convey the idea of a world in a state of per -petual ‘becoming’ These are statements about the nature of the world, andtheir repetition echoes the creation story – the world is ritually ‘recreated’

in them as a series of never-ending beginnings or births This idea is a keyaspect of the traditional M¯aori worldview Creation stories give people a way

of looking at their world These stories tell us about individuals acting inparticular ways and securing their position in the world They stand, therefore,

as a model for individual and collective behaviour and aspirations For M¯aorithe environment exists on several different levels at once A mountain can

be the personification of a particular atua, as well as being rock, a resource

to be utilized, and having qualities such as beautiful or cold This worldviewhas a number of connotations for our relationships with each other and theearth

The creation of the Universe for M¯aori also mimics the movement of Birth from the darkness of all potential where the archetypal parents werelocked in embrace to the movement into te ao marama, a time of light andunderstanding and the birth of the new world and ancestors as children I amcontinually reminded of the responsibility to birthing mama as our futureancestors and in reverence to the ones before then as a continual line of theirwhakapapa or genealogy In this place I too am honored and revered, I toohave whakapapa and this is a reciprocal relationship

The overriding themes for me in this book sit well therefore beside a M¯aoriworldview because they examine how our Kaupapa/philosophies shape ourinteractions with each other and our papa/our world, our whenua/ourmama/our earth That the responsibility to be mindful of our connectedness

as more than a rhetoric of holistic care means that we will live our lives in away that sustains and enhances our lives and world

I end on a whakatauaki/proverb/saying from my own tribe/Iwi of Ngai Tahu:

M ¯o t¯atou, ¯a, m¯o k¯a uri ¯a muri ake nei

– For us and our children after us

Amber ClarkeNgai Tahu

We would like to say a big thank you to a number of people who havesupported us with this project First, to the group of contributors who havefound the time and space in their busy lives to bring what we consider to be

an important book into being

To our long suffering colleagues Jacqui, Julie, Ruth and Amber who have

‘midwifed’ us through its gestation

To Kelly Dorgan and Janine Puentener for their images and their ‘goodhousekeeping’ modelling by using cycles in their practice lives and to LucyKennett for your ‘beautiful belly’ To Joanne Webber for taking on the role

as official photographer To Min and Richard at Beautiful Bellies for theirwonderful placenta print image

To our editing team at Routledge, Grace and Khanam, for having faith andencouraging us to break new ground in midwifery literature by publishingthis text

Finally, we would especially like to thank our families for their enduringpatience, understanding and support To Tom and Joe, Mark and Ruairi, andRichard and Laura

This book suggests that attention to sustainability involves more complexthinking than is implied by the simple injunction ‘do not breed’ After all,sustainability is about attention to the future As defined by the BrundtlandCommission, it ‘meets the needs of the present without compromising theability of future generations to meet their own needs’ (World Commission onEnvironment and Development 1987: 43) Across history and cultures, people’sattention to the future has been most obvious in reproduction Personal, family,community and political futures have been invested in bearing children andthe creation of future generations It is widely considered to be a biologicalimperative Thus, using the lens of sustainability to critically examine howwomen give birth and nurture their babies, the shape of maternity services andthe place of midwives is vitally important.

Sustainability has been placed in the public spotlight in recent years

through the climate change debates Documentaries such as An Inconvenient Truth (2006), Yen Arthus-Betrand’s Home (2009), fictional films such as The Day After Tomorrow (2004) and The Age of Stupid (2009) and inten-

sive media coverage of the Copenhagen Climate Change Summit in December

2009 have all contributed to growing awareness that the accumulation ofgreenhouse gases in the atmosphere through human energy consumption

jeopardizes the lives of billions of people on this planet The harmful healthconsequences of global warming extend beyond the loss of homes due to risingsea levels They include increases in infectious diseases (in humans andanimals), malnutrition due to food and water shortages, health risks associatedwith extreme weather events and the detrimental effects on mental health

all these can create (Maclean and Sicchia 2004; Patz et al 2005; McMichael

et al 2006).

The sustainability of life on this planet requires urgent attention to reducingour ecological footprint The concept of sustainability focuses on the future

of humanity and the relations between human beings and with all living things

in the environment McMichael argues that ‘For human populations,sustainability means transforming our ways of living to maximize the chancesthat environmental and social conditions will indefinitely support human

security, wellbeing, and health’ (McMichael et al 2003: 1919) Thus, atten

-tion to sustainability encompasses social, political, economic and ecologicalconcerns

Bioethicist James Dwyer suggests that we need to think about sustainability

as an ethical framework He states that we

need to develop norms and institutions that will help us to share fairlythe biosphere’s capacity to sustain life [T]he virtues that we needare social justice, international justice, a concern for the most vulnerable,modesty of demands, and the creativity to fashion healthy and good liveswith limited natural resources The vices that we need to avoid areignorance of our situation, the corruption of vested interests, the injustice

of taking more than our share, and indifference to the plight of others

(2008: 285)The underlying philosophy of the midwifery profession is essentially alignedwith sustainability Midwifery practice is about community-based primaryhealth, strengthening family relationships and promoting normal birth(International Confederation of Midwives 2005) A midwifery model approachthus promotes low resource use and the minimizing of unnecessary inter-vention The contribution that midwifery could make to sustainability byhelping to safeguard the health and well-being of new families by modellingless exploitative health care practices is considerable By supporting a sustain -able approach to practice philosophy, resource management and personal andprofessional sustainability, midwifery could ultimately lead the field in healthcare as a truly ecological and socially responsible profession

The book draws upon an interdisciplinary body of knowledge, includingecology, sociology, economics, political sciences and midwifery knowledge.The focus of the book is not a prescriptive recipe of ‘what to do’ and ‘whatnot to do’ Instead, it invites readers to reflect critically on the issues and toconsider how they could move to effect changes within their own personaland professional environment This book features a range of internationally

known authors with a longstanding interest in the politics of childbirth andmidwifery Although their names are not necessarily associated with sustain -ability issues, they all recognize the potential for sustainability to provide aframework in which to site midwifery philosophical and epistemologicalconcerns As editors, we approached these authors because we knew that theirwork and interests resonated with the broad principles of sustainability: therespect and commitment to protection of natural undisturbed birth (Odent2002) and concerns with social justice for women in childbirth We gave theauthors a very open remit with regard their subject specialism.

The book begins by introducing the reader to the concept of ability and birth by theoretically analysing the political issues relating tomidwifery and sustainability from a range of perspectives It sets the scenefor the book by exploring some of the universal ecological issues that influ -ence birth globally in the twenty-first century Section Two continues byexploring some of the strategies that may help to play a part in the develop -ment of midwifery as a formidable agent in sustainable health care practice.The third and final section focuses primarily on the politics and practicalities

sustain-of becoming a parent in the age sustain-of neoliberalism, with its continuing drivefor sustained economic growth

The politics of midwifery and sustainability

The profession of midwifery could be viewed as an anomaly within healthcare practice It provides for women who are generally in a state of healthrather than disease and although the interface with clients is episodic incharacter, the length of contact with women is frequently of a greater durationthan most health service encounters Midwifery is based around the philosophythat pregnancy and birth are normal life events and should be situated within

a social rather than a medical model (Pairman and McAra-Couper 2005) The midwife is expected to support the physical, psychosocial, cultural andspiritual well-being of the woman throughout the childbearing cycle, providewomen with individualized care, education and counselling, and mitigate theinvolvement of technological interventions and clinical intervention (MANAMidwifery Task Force 2004) The midwife should acknowledge the woman’sautonomy in her own life and respect the decisions she makes for herchildbearing experience (New Zealand College of Midwives (NZCOM) 2005).The role of the midwife is an ancient one, which predates all other healthcare practices (Towler and Bramall 1986) Traditionally, the midwife was avillage woman who learned her trade by attending the births of her familyand neighbours Skills and knowledge were handed down through generations

of women This was the case until fairly recently from a historical perspectivewithin Western countries, and remains to be the case in other non-Westernparts of the world today However, the medicalization of childbirth in thelast century has altered the role of the midwife It has led to an increasingtendency for women to birth their babies in hospital, an increasing reliance

on technology and mounting rates of clinical intervention Consequently therole of midwife in many countries has been reduced to that of a medical aide(van Teijlingen 2005).

The technocratic approach to childbirth has escalated the economic andresource costs of maternity services without equal gains in the safety of child -birth This was combined with neoliberal influence of the 1980s and 1990s inthe design of health services globally through the World Bank who viewedhealth in terms of tradable commodities and services in the marketplace ratherthan a public good (McCoy 2007) In this discourse, natural childbirth becameviewed as an individual lifestyle choice in the maternity services market placeand vested economic interests have lead to women being persuaded to pay forobstetric care even when they are experiencing a normal pregnancy (Epstein,2008)

The issues related to the medicalization and commodification of childbirthare explored in several chapters within this section Jo Murphy-Lawless beginssetting the context by exposing the gap between the language of midwivesand childbirth activists and the language of capitalism within health carepractice Ina May Gaskin is critical of the technocratic/medicalized approach

to childbirth and asks where we can find alternatives that are more holisticand sustainable for the future In Chapter 3, Sally Tracy argues that the currentobstetric regime is unsustainable, economically and socially She critiques theinequitable distribution of resources that is fostered by the neoliberal design

of maternity services Zoë Melleo-Erwin and Barbara Katz-Rothman take upthis theme and examine its implication for the social meanings attached towomen’s bodies and fetus/babies in relation to commercial surrogacy

Midwifery as a sustainable health care practice

In recent decades midwives, supported by the women with whom they haveworked, have fought to re-establish midwifery as an autonomous profession incountries around the world (Reid 2007) This has been particularly notable in New Zealand where a renaissance of midwifery as an autonomous professionhas been able to effect the establishment of a national, state-funded maternityservice based on continuity of care and carer The NZCOM ‘Partnership Model’(Guilliland and Pairman 1995), which underpins the organization of maternitycare in New Zealand, aims to ensure that the delivery of care is a collaborativeaffair, with women clearly staking their claim in the process It is a system thatenables midwives to truly work within a framework of continuity and to bewith woman in a holistic sense In Chapter 5, five authors, led by Nicky Leap,introduce and reflect upon the characteristics of some of the working modelsthat may provide a sustainable ‘habitat’ for midwifery practice

The relationship that a midwife has with a woman within the continuum

of childbearing is a unique one This is particularly so when both the womanand the midwife are privileged enough to work within a continuity of carermodel, and get to know each other over a number of months, during a period

where personal growth figures significantly for the woman It is theorizedthat this relationship is a significant factor in achieving well being, whichbestows an important role upon the midwife stretching far beyond addressingthe physical needs of the woman as defined by the medical model (Thompson2003) Mavis Kirkham refers to this concept, which she describes as ‘the flow’within Chapter 7.

Midwives working within a continuity care model may be in a position tohelp to safeguard the health and well being of new families by modellingless-exploitative health care practices and promoting a holistic approach tocare In Chapter 11, Ruth Martis explores the ‘housekeeping’ practices ofmidwives and suggests that by promoting a sustainable approach to practicephilosophy, resource management and self preservation, midwifery has thepotential to provide a valuable contribution to sustainable health care.Midwives need to find ways of working that allow them to sustain theirphilosophy and their practice These include nurturing their emotional wellbeing, supporting their fledgling practitioners and educating for sustainablepractice These areas are addressed in Chapters 6, 9 and 10 by Ruth Deery,Sally Pairman and Mary Kensington respectively

If we consider the structural framework of ecological theory in relation topregnancy and the immediate post-natal period, they could be said to represent

a unique ecosystem Mammals are described as developing through a series

of ‘habitats’ During pregnancy the habitat is the uterine environment Within

a specific habitat, the nascent organism is believed to be neurobehaviourallyprogrammed to behave in a way that will enable it to provide for its ownneeds This pre-programmed behaviour can be described as the ‘niche’ Oncethe baby is born the habitat is embodied in skin-to-skin contact and breast -feeding represents the ‘niche’ or pre-programmed behaviour designed for that habitat (Bergman 2005) The midwife has a hugely important role toplay in facilitating this ‘econiche’ In pregnancy, the midwife can work withthe woman in helping her to indentify some of the environmental and lifestylefactors that she may be advertently or inadvertently exposed to Suchidentification may direct the woman to consider ways in which she coulderadicate some of the risks where possible, or at least to mitigate the effects.Megan Gibbons and Jean Patterson examine some of more common hazardswithin Chapter 14 The actions of the midwife in protecting, promoting andpreserving the significance of the mother–baby dyad in pregnancy, duringlabour and birth and in the early hours, days and weeks of new motherhood

is of paramount importance It has been proposed that the mother–babyrelationship could be viewed as the prototype of all relationships (Odent 1999)

If the baby is able to establish a reciprocal and loving relationship with itsmother, it is more likely to be able to connect with others along its life’sjourney and to establish successful relationships (Bergman 2005) Thesefactors are analysed by Carolyn Hastie within the context of the environment

of birth in Chapter 8

Supporting and ecological approach to parenting

Consumerism can be viewed as having an immeasurable effect on theexperiences of parenting (Louv 2005) The growth in the market of ‘parentrelated industries’ could be seen to be transforming the norms of motherhood

in western industrialized societies Women appear to be faced with increasing demands of juggling work/life balance in order to deal with thecomplexity of their lives Many of the solutions offered seem to be based aroundincreased use of goods and services The dynamic relationship betweenconsumption practices and parenthood are explored in this section of the book

ever-A relationship referred to in analysis around social sustainability is therelationship that we have with ourselves (Layard 2003) Various authors havesuggested that our consumer-driven society has encouraged us to develop ouridentity around what we have and do, rather than who we are (Thomas 2007;Schwartz 2005; Travis 2000) It could be argued that this makes us dependent

on others for our self esteem It has been said that personal happiness andwell being are equated with autonomy, achievement and the development ofinterpersonal relationships and less with the acquisition of material wealthand goods (Kahneman and Sugden 2005) Midwives, by educating, encour -aging, supporting and listening to women, have the opportunity to assistwomen in building self esteem and personal resilience This is explored byLorna Davies in Chapter 12

Childbirth and parent education sessions are another vehicle that can be used

to help women to connect with others in their community In Chapter 15, MaryNolan suggests that this may promote relationships and encourage women

to establish their own new network of friends and support By encouraging the active involvement of the woman’s partner or her family members, existingrelationships may additionally be strengthened

A simple way of promoting the ‘econiche’ of the mother–baby dyad is bysupporting the practice of breastfeeding This ancient practice provides animportant renewable natural resource Its production and delivery take placewithout the use of other resources and it creates few disposal problems Incontrast, infant formula expends a great deal in environmental costs, at everystep of its life cycle It also contributes towards the deaths of million babiesevery year and causes ill health in countless others (Palmer 2009) Carol Bartledescribes the proliferation in the use of breastmilk substitutes as a ‘globaldisaster’ and reframes the significance of breastfeeding within an ecologicalcontext It is believed that skin-to-skin care enhances the effects of lactogenesisand features in the establishment of attachment and co-dependence of motherand baby Co-sleeping can be viewed as a continuation of skin-to-skin care(Newman 2008) Until relatively recently, co-sleeping constituted a pre -requisite for infant survival, because it ensured that the baby had an unlimitedaccess to breastmilk This is still the case for many mother and baby pairingsoutside the western industrialized context This significant human behaviour

is therefore introduced as an ecological parenting practice by Sally Baddock

in Chapter 16

Finally, Rea Daellenbach and Nadine Pilley Edwards deconstruct contempor ary challenges for contemporary childbirth activists who want to advocate forundisturbed birth They suggest that women and midwives need to worktogether in order to ensure the sustainability of childbirth services not just forthe individuals concerned but for the wider community as well.

-The book ends with a creative piece that was originally written as a radioplay that celebrates the deep connections between the woman, the baby, theplacenta and the planet Earth

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Section one

The politics of midwifery and sustainability

1 Globalization, midwifery and

maternity services

Struggles in meaning and practice

in states under pressure

Jo Murphy-Lawless

Keywords and birth policies

Few words are more persuasive than ‘woman-centred’ care and led’ care to describe what should comprise the best of support for women inlabour and birth They are often used alongside the notion of ‘choice in child -birth’ and many of us believe that we can define the principal characteristics

‘midwifery-of all three terms

However, as the cultural theorist Raymond Williams reminds us, defini tions are crucially dependent on one’s interpretive framework In his important

-study, Keywords: A Vocabulary of Culture and Society, Williams described his

puzzlement about the meanings of the word ‘culture’ in post-World War IIBritain He saw that the word was marked by a struggle between two broadbut competing social groups: a bourgeois class who wanted to define the term

to favour elitist interpretations only and thus to exclude all other meanings,and a working class that was anxious to valorize distinctive cultural practicesthat were far more wide-ranging and inclusive Despite the contested groundbetween them, there was a sense that both sides understood what was meant

by ‘culture’ Williams observed that we all have a repertoire of such wordsthat we use in an effort to establish meaning even when there is a struggleover how that meaning is applied

‘Keywords’ comprise a

general vocabulary ranging from strong, difficult, and persuasive words

in everyday usage to words which, beginning in particular specializedcontexts, have become quite common in descriptions of wider areas ofthought and experience This, significantly, is the vocabulary we sharewith others, often imperfectly, when we wish to discuss many of thecentral processes of our common life

(Williams 1983: 14)The pattern Williams captures in this passage, words from specialized contextsthat come to possess fundamental powers of persuasion and rightness and aboutwhich there appears to be a general, if imperfect, understanding, can also be

seen in the current keywords used about birth and midwifery We know there

is a vigorous struggle about what constitutes ‘choice’ and ‘woman-centredcare’ and about the context necessary to achieve these aims for women AsSheila Kitzinger has observed (2006: 88, 158), the woman who ‘chooses’ anepidural or a Caesarean section is often not taking a decision so much as she

is endeavouring to protect herself in a setting where her fears are goingunaddressed and her support needs neglected, making this an enforced ‘choice’.The term, active management of labour (AML), also presents us with astruggle about meaning In the National Maternity Hospital, Dublin, whereAML dominates maternity care, it is defined as ‘midwifery-led’ care (O’Driscoll

et al 2004: 1; Hunter 2010), a notion that would be hotly contested by

mid-wives working in free-standing birth centres (Walsh 2006) or in independentgroup midwifery practices (Reed and Walton 2009) where women andmidwives genuinely work in partnership particular to each woman’s needs.There is another group of keywords that is far less commonly used in debates

on childbirth but which nonetheless bears examination for their impact onmidwifery and our maternity services ‘Globalization’, the ‘modernizing state’and ‘privatization’ are three concepts working at a meta-level that are reshapingthe location and control of maternity services This shifting pattern is seenmost readily in countries that heretofore have had a commitment to the welfarestate Many states have now moved decisively away from their work ofproviding core services and towards well-known tenets of ‘neoliberalism’, seen

as a building block of market globalization David Harvey (2005: 2, 3) hasdefined neoliberalism as an economic theory that prioritizes ‘entrepreneurialfreedoms within [a state] institutional framework characterized by strongprivate property rights, free markets and free trade’ These objectives arepromoted as the best route to maximizing widespread benefits for all by

‘maximizing the reach and frequency of market transactions’ (Harvey 2005).Despite the contention that all people are helped to a better way of life underthis economic regime, the move to ‘bring all human action into the domain

of the market’ (Harvey 2005) has led to the erosion of the state’s commitment

to a public health care system which, up to now, has been free at point ofaccess and has been seen by ordinary citizens as a common social good(Bauman 1998a; Mishra 1999; Esping-Andersen 2002) The principal impetusfor the move away from a state-supported and state-funded health structure

is the increasing level of profit to be gained from the commodification ofhealth (Shaffer and Brenner 2004: 86) Turning health services into a com -modity to be bought and sold in some form or other is the cornerstone of theexpanding ‘global market’ in health care that is conservatively valued at morethan 3.5 trillion dollars (Bulard 2003) This commodification of health isprimarily an American model, where since the 1970s, and the introduction

of Health Maintenance Organization (HMO) legislation in 1973 (Gruber

et al 1988), ordinary people have had to pay into these private sector HMOs

for health insurance cover It has produced a vastly profitable business, withcripplingly high rates of insurance helping to inflate health care costs for

individuals, while HMOs, along with the pharmaceutical and medicaltechnology industries, have enjoyed record returns Moreover, the creation ofHMOs garnered extensive federal funding to help put in place what wereseen as public-private partnerships, a term that we will return to below.

In relation to childbirth, turning it into an insurable commodity has led to a ‘market share’ in the United States that in 2000 entailed for every

100 live births, an estimated 84 applications of electronic foetal monitoring,

67 ultra sound screenings, 23 Caesarean sections, 20 inductions of labour, 18accelerated labours, and seven vacuum or forceps extractions (Perkins 2004:12) Based on figures from the Health Insurance Association of America,Perkins (2004: 13) estimates that by 1993 national expenditure on pregnancy,birth and post-natal care, largely channelled through HMOs, came to 40billion dollars, with obstetrical interventions and neonatal intensive careaccounting for the lion’s share of these costs Despite this, the rates of perinatalmortality worsened throughout this period (ibid.: 12) and by 2003 the UnitedStates stood at the bottom of perinatal rankings for 23 developed countries(Lane 2008: 30)

Pressure groups from the corporate health sector, anxious to increase theglobal scope of the health care market, have played on growing fears expressed

by influential international organizations such as the International MonetaryFund (IMF) and the World Bank that national governments could not affordtheir ‘social contract’ to underwrite health and welfare costs if they were toremain internationally competitive (Mishra 1999: 7; Bulard 2003) In 1995,after the establishment of the World Trade Organization, the General Agree -ment on Trade in Services (GATS) extended international rules governingmultilateral trade to include health as a tradeable commodity across nationalborders to the benefit of these corporate industry interests (Shaffer and Brenner2004: 92) This move licensed the expansion for the corporate health sector

in countries that had tried to maintain strong public commitment to healthbut which now privatized and outsourced aspects of care with accompanyingsteep rises in administration costs unconnected with frontline services (Shafferand Brenner 2004: 86; Pollock 2004: 37; Burke 2009: 84–86)

Alongside other complex factors, this aspect of global trade has impactedadversely on health outcomes and made life more uncertain for many millions

of people For example, international improvements in the drop in infantmortality rates did not continue past the 1970s (Bezruchka and Mercer 2004:15) Two countries that have managed to preserve their health services, andthus better health outcomes, are Sweden and Cuba (Bezruchka and Merceribid.: 16–17) However in neither country is there a particular emphasis onwoman-centred care, and indeed in Cuba, home births are illegal (Sjöblom

et al 2006; Murphy 2008: 392).

I have sketched out a multi-layered scenario about birth and health thattakes us away from the more specific contests about what constitutes woman-centred and midwifery-led care and points to the intricate frameworks withinwhich our maternity services are located at the level of the state In this chapter,

I will argue that it is crucial for our grasp of the depth of the struggles thatare coalescing around how maternity services are developing to bring theseterms about globalization, the modernizing state and privatization into ourdiscussions Examined as a group, they present us with profound challenges.

I want to discuss the impact of these terms, using examples from currentevents and contexts of birth in Britain and Ireland While the details arespecific to those two settings, the underlying issues have resonance for women,birth activists and committed midwives across the world I will concludebriefly with a word about activism that may prove helpful to movementsworking to protect health as a common social good internationally

The big picture: globalization and the changing role

of the state

There is a sizeable debate on the meanings and extent of globalization(Cameron and Palen 2004) Nonetheless, certain characteristics mark out thiskeyword that affects us all, although the impact is neither monolithic noreven Yeates (2001: 4) offers the following as a ‘basic’ definition: ‘an extensivenetwork of economic, cultural, social and political interconnections andprocesses which routinely transcend national boundaries’ Bauman (1999: 28),following the arguments of Pierre Bourdieu (1998: 95) and Erving Goffman,adds that this is a ‘strong’ discourse, which favours one dominant form ofeconomic relations, a particular notion of how ‘free markets’ should function,over others These economic relations are often associated with offshorecorporations with an international reach, that is, they are unconstrained bynational boundaries They have the capacity to operate in a flexible manner

in the way they shift finance, technology and labour needs (often downsizingthe latter) across the world while avoiding tax regimes that are seen to detractfrom their profitability for shareholders It is the force of this offshore character -istic of flexibility that is especially troubling Bauman (1998b) speaks of aglobal elite of corporate and international experts who routinely moveuntroubled across national boundaries The notions coming from this elite ofwhat reforms to national infrastructure will best contribute to increasing globaleconomic growth are readily picked up by national governmental bodies.Cameron and Palen (2004: 7) speak about this version of globalization as a

‘pervasive narrative’ that assumes the status of an unassailable ‘truth’, whichhas altered dramatically what we think of as the work of the state

This narrative (there could be others) has rewritten in concrete terms the

‘technological, economic and institutional’ processes we have seen as part ofour society, while also rewriting the role that the state has held in trying tounify and prioritise our various needs and concerns (Cameron and Palen 2004:7) This narrative asserts that there is a need to ‘modernize’ the state which,with little or no consultation of its citizens, appears to involve a reprioritization

by the state of its core commitments These need to be minimized or evendropped in order to help create a more flexible national space to support

economic growth The keyword ‘privatization’ comes to the fore here and isaided by moves towards ‘liberalization’ and ‘deregulation’ (Cameron and Palen2004: 16) to help ‘streamline’, that is offload, the state’s responsibilities Theargument is that these changes in tandem improve national competitivepositions in an increasingly competitive international climate by opening upnew markets and new possibilities The work the state has done in the past,which we as ordinary citizens have welcomed in relation to health, educationand welfare, has altered as a result, as has the way the state speaks of itsresponsibilities.

Coming from the top: changed priorities for maternity

services

This shift is most jarring in relation to health In Britain, the modernizingstate has visited four major programmes of reform on the NHS in the lastdecade (Sennett 2008: 46–47), converting it into a version of the marketplace

so that the health service might function as a more ‘rational’ distributor ofwhat is now seen as its goods and services As a result of these reforms, thehealth service from the top down has promoted notions of targeting, efficiencyand cost control that come from the domain of corporate capitalism We can

no longer speak about a health service available to all on the basis of individualneed, within which midwives, nurses and doctors can take pride in their work

as a deeply respected set of skills, with truly able craftsmen who take time

to learn, to practise and to deepen their judgment (Sennett 2008: 50–51).Sennett argues further that the base, which enables genuine skill to bedeveloped and transmitted to new entrants to these professions, is under threatamidst a drift towards mediocrity due to the pressure to achieve performancetargets Sennett’s analysis is seconded by Allyson Pollock (2004), who hasexamined the privatization of the NHS to the detriment of the general publicwho rely on it – creating hundreds of competing quasi-private companies

in the form of trusts and foundation hospitals to tender for the provision ofhealth services This has led to poorer services, poorer outcomes, increasing healthinequalities and the demoralization of health care workers Pollock (2004: 4)pointedly observes that this marketization of the NHS, with its accompanyingrhetoric around ‘public-private partnerships’, created a ‘revolving door’ so thatthe private sector businesses of finance, management and construction haddirect access in shaping how planning and management functions of the NHSmight be privatized Despite that word ‘partnership’, public-private partner-ships (PPPs) or private finance initiatives (PFIs) have given taxpayers nodemocratic say in the evolution of new hospitals, while the PPPs and PFIshave helped to create an unequal burden – ordinary citizens bear the directand indirect costs of privatizing these functions, creating greater inequalitiesfor many While the private sector has benefited enormously from the profits

of the restructured finance required by PFIs, people who must use hospitalsand who work there must bear the reduction of annual care budgets, reductions

in permanent staff numbers and beds, reduction in pay, and poor qualityhospital plant to finance this most expensive form of funding with the highinterest rates that PFIs entail (Pollock 2004: 97–98).

Midwives and midwifery have been under peculiar pressure within thiswelter of restructuring On the one hand, birth support groups, supported

by parliamentary review committee findings, along with the Royal College

of Midwives and many dedicated practising and research-based midwives, haveconstituted a broad coalition to promote woman-centred care The scope ofthis care has been refined in successive national policy documents in whichthe midwife is viewed as the lead professional working in partnership tosupport a woman to achieve what is best for her The government mantra is

‘choice’ On the other hand, the strains from a continually restructured andincreasingly under-resourced health service, which is chasing paper efficienciesand throughput targets, come on top of the effort to change a midwiferyculture that has been reluctant to embrace midwifery-led care In too manyinstances, midwives feel unsupported and exhausted, leading to their burningout and leaving the profession (Deery 2005) In 2009, the Royal College ofMidwives published the results of its survey carried out with heads of mid -wifery that showed some of the heavy costs of a commodified health service.Despite some recent additional government funding to deal with a shortage

of 4,000 midwives, maternity services face an increasing birth rate, but a reduc tion in midwifery budgets, high long-term vacancy rates, ongoing problems

-of recruitment and retention, massive workloads, stress and burnout (RoyalCollege of Midwives 2009)

Woman-centred midwifery care has fared no better in Britain’s nearneighbour, Ireland This was an impoverished agrarian society dependent onemigration through the major portion of the twentieth century and lagging

25 years behind British society in challenging the public patriarchy of thestate and of medicine (Kennedy and Murphy-Lawless 1998; Murphy-Lawless

et al 2004; Devane et al 2007) In the mid1990s as Ireland began to partici

-pate more completely in the globalized economy of transnational corporations,foreign direct investment and the financial services sector expanded employ -ment after decades of underfunding in the health services led to a return

of emigrants from Britain and elsewhere This included midwives anxious

to make changes and build alliances with midwives already in post to bringabout that change It should have been possible in a small country Yet Irishwomen no sooner gained maternity services free at the point of use for all,than private health insurance-funded consultant obstetric care expanded its already considerable options The same obstetricians who reinforced a rigid hierarchical culture, overseeing consultant-led policies, such as activemanage ment of labour in the major public hospitals, encouraged privateantenatal care that provided them with a lucrative income in addition to their generous public contracts The growth of private facilities contributed

to an increase in interventions, seen clearly in relation to the steep rise inCaesarean sections (Cuidiú 2008; Brick and Layte 2009) That trend in the

private sector continued to merge in subtle and not so subtle ways withinthe public sector, where committed midwives worried about their lack of skill

in supporting normal birth while intervention rates rose (Murphy-Lawless 2002)

By 2001, with a steep increase in birth rates, directors of midwifery expressedpublicly concerns about overstretched resources with too few midwives in post(Haughey 2001) This picture was bucked in some part by a handful of pilotprojects including direct entry midwifery teaching, ‘domiciliary in and out’(DOMINO: continuity of care, but with the option of hospital as well as homebirth) and home birth schemes and a tiny community midwives group backed

by the voices of equally small birth support groups A local political struggleover the closure of hospitals in 2001 led to the important work of setting upand evaluating the first midwifery-led units from 2003 (School of Nursing andMidwifery 2009) The official Domiciliary Births Group, convened in 2004

to consider domiciliary births, recommended more broad-ranging strate gies,but the impact of the group’s report was minuscule measured against the weight

of the consultant system of care There was no concerted national impetus fromthe top of government to review the problems and scope of maternity servicesacross the country, nor to consider the need for midwifery-led care throughthe official policy-making process that begins with a White Paper

In fact, the national Department of Health was preparing to shed many areas

of direct executive decision-making and to ready the country for a new indirectand democratically less-accountable monolith, the Health Services Executive

A private management consultancy firm was awarded an audit of the healthservices and the findings, along with several other reports, led to the launch

of a Health Services Reform Programme to ‘modernize’ the health services,introducing the notion of an internal market There was an over-representation

of private sector finance people on its new board (Burke 2009: 50–53, 55).While there was clear need to properly undertake new infra structure andinnovations within the public health system after decades of neglect, cutbacksand parochial decision-making, this reform strategy instead placed Irelandfirmly on the road to expanded private health care consortia, including tie-upswith international corporations The public sector continues to subsidiseprivate beds in public hospitals, including maternity hospitals, while the growth

of private for-profit hospitals has been actively supported by government, withgenerous tax incentives (Burke 2009)

The new Health Service Executive (HSE) in the meanwhile operates as apeculiar hybrid with salaries and perks that reflect top private-sector pay forits CEO, other management executives and its freelance management consult -ants and, as of 2009, deep cuts in pay and permanent embargoes on posts forfrontline staff who have already lived with a series of temporary embargoes(Burke 2009: 87–88)

There has been chronic overcrowding in the four largest maternity hospitalsover the last decade; one hospital hired nearby hotel rooms for patientsneeding daycare in 2007 Currently women in all these hospitals are told thatthey must book for antenatal appointments as soon as their pregnancy is

confirmed, as they are otherwise unlikely to be seen for the first time untilthey are well into their second trimester (Ingle 2007; Donnellan 2009) Thehead obstetrician of one hospital has voiced concerns about patient safety and has sent internal reviews about the serious shortage of resources to theHSE with no response (Ingle 2007) Unsurprisingly, midwives and midwiferystudents are feeling the acute strain of working in such pressurized condi-tions, which makes woman-centred, midwifery-led care feel unobtainable The average length of booking visits in hospital is thought to be often aslittle as 15 minutes.

A commissioned report for the HSE by the international managementconsultancy firm, KPMG, confirmed significant understaffing in the threeDublin maternity hospitals, as well as lack of privacy, too few delivery suitesand too many Nightingale-style wards Its solution, however, was to mergethese standalone hospitals, centralizing their services within existing acutehospitals, citing the commercial value to the health services of selling off the vacated properties While the report called for an expansion of communitymidwifery, nowhere did it articulate how this could be achieved given theembedded nature of private obstetric care (KPMG 2009) The latest NationalHealth Service plan does not say anything specific about maternity services

in any form (HSE 2010) It does, however, lay out performance indicators,targets and ‘deliverables’ all of which, according to the CEO of the HSE, need

to be accomplished through greater effectiveness in how services are deliveredwithin current pressures to reduce costs (Taylor 2010)

The contradictions: under-regulation and over-regulation

These brief overviews of maternity services in Britain and Ireland indicatethe extent to which they have been permeated by the language and perspectives

of states that have moved steadily towards a ‘globalizing co-partnership’ withprivate capital interests In this relationship, the state becomes ever more

‘market-oriented’ (Wolin 2008: 238) and ever more distanced from andseemingly uncomprehending of its detrimental impact on the people whosehealth it was once meant to support Where midwives, nurses and doctorsmight have aspired to a kind of generosity in working in the public healthservices, they are now reduced to the sum of their ‘deliverables’ under so-called efficient targeting, and the very notion of a public service is questioned.Even the King’s Fund in Britain, an independent think-tank that recentlyexplored the worrying issue of safety in English maternity units (O’Neill 2008)and that might have been expected to challenge this rhetoric, has fallen prey Their annual conference in 2009 focused on how further change candeliver more efficiencies, greater productivity and, they argue, improvedservices

Despite the rhetoric of improvement, there are only small pockets wherethis has been genuinely secured for women and midwives Much of this isnow under threat from the profound convulsions of the last two years If before

2007–2008, one was unaware of any troubling implications of that keywordglobalization, the sudden appearance of the ‘global banking crisis’ broughtinto sharp relief for countless people that corporate finance working on a globalscale had seriously jeopardized their everyday well-being The crisis of theunregulated corporate finance sector flowed remorselessly into the ‘currenteconomic crisis’ The connection for many was bank bail outs State govern-ments around the world began to cut back public expenditure on the coreservices of health, education and welfare, while unemployment and the burden

of public debt grew Health was a particular target In the wake of taxpayerrevenues being used to refinance the banking sector, the IMF warned Britain

it must cut the NHS in order to deal with increased public debt (Elliott 2009)

In Ireland alone, 80 billion Euros of tax revenues were targeted to shore upthe banking system

Slavoj Zizek (2009) argues that the extent of this crisis lets us see howdeeply irrational the fantasies of globalized capitalism are and equally howswiftly governments move to act to protect what they see as their real interestsand priorities, which are not the same as ours The speed with which fundswere taken from the public purse to accomplish the bank bail outs while healthbudgets suffered cuts is chilling It also suggests a deeply anti-democraticbias in the way these decisions are made The electorate has not been giventhe chance to make a choice between bank bail outs and swingeing cuts ingovernment-financed services The complex outcomes of this fantasy have donegreat damage to our health services, including our maternity services As justone example, the award-winning Montrose Midwifery Unit in Scotland hashad plans for a new purpose-built unit suspended indefinitely (Birth in Angus2010) The proliferation of agencies the modernizing state has set up ostensibly

to protect us actually creates less transparency and accountability (favouredwords from that corporate world), while exerting control over areas where wemost need to remain open and reflexive Britain has made this concretewithout a hint of irony, setting up ‘Arm’s Length Bodies’ (ALBs) as a ‘network’

to ‘manage’ the NHS These bodies have an association with and aregovernment-funded However, the state has now privatized expertise whileintensifying its regulatory apparatus – ALBs are not directly democraticallyaccountable to us through government though they speak of ‘governance’.The state has fragmented and scattered its work so we are far less able toaffect decisions and outcomes, even while it has more bodies to monitor us.Sadly, in Britain this movement has led to the demise of a crucial instrumentfor improving maternal health, The National Confidential Enquiry intoMaternal Deaths, once a committee reporting directly to the Minister forHealth and internationally respected for its rigorous work, this has become

a private ‘charity’ The Centre for Maternal and Child Enquiries (CMACE),funded only in part by an ALB known as the National Patient Safety Agency,needs to fundraise through open tenders elsewhere and can no longer practisewithin the scope and reach of its original work These unaccountable networksconfuse and disorientate even as they disempower ordinary citizens

The under-regulation of the financial sector contrasts sharply with this regulation and monitoring of health, a pressing matter for midwifery inparticular Within what Bauman (1999: 173) terms the ‘political economy

over-of uncertainty’, midwives who are working creatively and openly in partnershipwith women come under increasing and troubling scrutiny for standingoutside a deeply questionable systematization of birth Thus recent cases takenagainst independent community midwives (Beech 2009) and, above all, theenforced closure by King’s College Hospital of the beacon Albany MidwiferyPractice, aided in part by a report from CMACE (Reed 2010), signal an anxietyabout any midwifery practice that cannot be monitored with the targetingstrategy now in vogue to measure ‘outcomes’ In the instance of the Albany,its outcomes working in an impoverished community have been second tonone, yet its mode of work contests the direction that mainstream maternityservices are taking within a modernized, privatizing state

The Albany, Montrose, midwiferyled units in Britain and Ireland, inde pendent community midwives – all have reached out to protect and nurture

-a sp-ace th-at the st-ate -as -a whole is seeking to -ab-andon in rel-ation to birth,along with many other projects about the common good In a curious way,this is helpful The concerted campaign to save the Albany shares the samecollective space that is increasingly seen in other crucial public campaignswhere people fight for improved welfare services or housing or vital environ -mental measures This space is using evidence and activism, identifying andanalysing the keywords that are anti-democratic in their operations, retrieving

a language that truly speaks for the perspectives that relate to ordinarypeople’s lives, for where people are fighting to take back control of their lives

It helps us to see where we must make common cause

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